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Nursin’ USA - The trouble with early warning signs

6 March, 2010

Nursing Times’ resident US nurse Sara Morgan is struggling to understand the point of early warning scores. Shouldn’t all good nurses already know their way around vital signs?

As an emergency room nurse by background and first love (and yes, I will be using ‘ER’ instead of ‘A&E’ for the duration of this post) I live and breathe vital signs (or ‘observations’, if you prefer). After years spent triaging patients, I’ve learned that you can tell a lot about a patient’s state just by talking to them, but you can’t make a final assessment until you know their vitals.

There was the man who came into my ER one winter, smelling of alcohol and seeming just like many other homeless men who had used cheap wine to keep warm, until I checked his vitals and realised that he was slurring his words not because of his drinking, but because his core temperature was 32C. And then there was the woman with the history of migraines who came in with a headache. Was she having another migraine? Or was it her blood pressure of 280/145 that was causing her headache?

All of which makes me really frustrated with early warning scores, which I first encountered here in the UK. I understand the theory behind them — when enough of the vital signs are outside of the normal range, the EWS goes up, triggering a response from the nurse, HCA, or whoever records the vitals.

My problem with the EWS is this: why do nurses have to waste our time deriving a score from data that we already have to tell us what WE SHOULD ALREADY KNOW. That’s right — if a patient is going bad, the nurse should know from the vital signs themselves, not from a secondary score that is calculated afterwards.

Knowledge gap?

Why would a patient with a blood pressure of 80/55, heart rate of 120, respirations of 26 and a temperature of 39 be stable, but the resulting EWS of something like 47,000 suddenly make the nurse think twice about the patient’s status? When I have asked this question of colleagues, the response that I usually get is that many vitals are taken by non-registered staff. Does that matter?

Anyone who is collecting vital signs on patients should know when vital signs are abnormal and know what to do with that information. If there is some segment of the nursing workforce, trained or untrained, which is failing to notice deteriorating vitals, then is an additional box-ticking exercise suddenly going to make them pay attention?

The wrong solution

The creation of the EWS score is a solution to the problem of healthcare staff failing to recognise deteriorating patients, but it is the wrong solution. First, it adds more work and documentation to the nurse’s already heavy load. Second, if we as nurses are not interpreting vital signs correctly, why would we be any better at crunching that data into a new number and then acting on that result any more appropriately than we had on the original vitals?

And lastly, the EWS score completely ignores the subtleties of vital signs that make up the ‘art and science’ of nursing care. An oxygen saturation of 90% might trigger a call to the doctor under the EWS system, but an experienced nurse will recognise that for particular patients, a COPD patient for example, 90% oxygen saturation is entirely appropriate.

What about a stroke patient who is aphasic, but has a suddenly raised heart rate? That heart rate might be the only indication that the patient is in pain, which is easily treated with prescribed medication, rather than taking time to chase down a junior doctor to tell her that the patient’s EWS has changed.

Clearly, EWS scores were designed to keep our patients safe — a goal that we all aspire to. But if that is the only thing that lets a nurse or HCA know when there is a problem with a patient, then I think it’s time that we as a profession acknowledged that there is a problem with how we are trained to gather and interpret vital signs. We need to solve the problem at its root — in our training — and not with a new box to fill out on a piece of documentation.

Readers' comments
(36)

Anonymous | 7-Mar-2010 9:33 am

I agree entirely. So much is into schemes and systems and yet the true nurse (so I was told in my training in the 80s) looks at the patient as a whole from head to toe noticing vital signs, verbal and non verbal responses and then develops an instinct that is totally patient contact led and tells you straight away something is up. This instinctive reaction is often faster than filling in another form as mentioned in article above. Certain things trigger warnings and certain knowledge and logic makes sense of them. Are we now too cleve for basics. Is that what degree nursing does (oh and by the way I do have a degree but learned common sense first).

You are 100% correct. The additional tick boxing makes matters worse. Patients become failure to rescue statistics when RN staffing is poor. Additional paperwork will never solve this problem.

I was left as one RN to 25 medical patients the other day. My only help was a teenager. He was an untrained carer from some agency. He could not take vitals, blood sugars, or do any lifting due to a "bad back". We were the entire staff on that ward for 12 hours.

Filled in the usual incident forms and called the chief nurse, matrons etc. Was told to "stop complaining". I finally demanded to speak to the chief exec. But he/she is refusing to communicate with me.

It sounds like this EWS is a highly dangerous system and prone to error and precious loss of time in a critical situation in a busy clinical area where urgent treatment might be more appropriate for the patient than filling in more forms. It is each individual vital sign, including the visual appearance of the patient and other signs and symptoms that are the warning system not a statistic. Nurses, and others observing patients and measuring vital signs, are, or should be, well trained in and responsible for recognising any abnormalities and taking appropriate action. Why are nurses and trained HCAs in the UK never trusted to use their training, expertise, experience and intuition and do the job they have been trained for and know how to do best.

What happened to the end of the bed test.Your patient is a whole being not just a urine output in an hour .many of those trained in the late 70's early 80's will be looking toward retirement in the next 5 - 10 years, we need to address the basic common sense short fall nowSome of us will be patients and I for 1 want to be assured of a nurse who doesn't use a chart to determine whether or not I am sick

I agree with the author, however as newly qualified nurse I do like the EWS (or MEWS). I've been trained on it as a student, however I have seen how it can lead to more work and as some of HCA's I work with do the vitals they just fill it in and do not think furthwer than that. When I do the vitals I look at the trend and the patient. I dod believe that with the culutre of getting sued/ struck off that we have a soviet era work mentality and that this will paralise us when we need to act.

I absolutely agree. Nurses should be trained to be critical thinkers and problem solvers not number crunching computers. They should not need a MEWS chart to tell them that a patient is deteriorating. Anyone who is allowed to take observations should know the difference between normal and abnormal and the appropriate action to take.

Excellent article. You might want to know that some of us practice the common sense you are discussing. We tick the boxes afterwards. As someone who primarily worked in Psychiatric facilities, similar issues can be seen in Mental Health settings both here and in the USA. Examples are the compulsory completing of the BPRS (brief psychiatric rating scale) in acute admissions wards and other settings. Experience, knowledge, and understanding can generally tell you that someone's score for agitation might be sky high BUT then again, they have spent a morning at the GP, followed by 2 hours waiting for a duty CPN and finally being admitted into a bay with a floridly psychotic patient. The BPRS might pick up stuff at the point of assessment which is totally irrelevant if not placed in context. I remember nurses who did excellent things like predict the risk of violence or suicide being pulled up at the Performance reviews for NOT having a BPRS assessment in each of the case notes for the patients they are looking after. Crazy, i dont think this is a UK failing, i think it is a failure of common sense. You do realise though, that there are layers of middle managers whose jobs are secure as long as these redundant processes and requirements are in place????

I absolutely agree! The EWS isn't perfect (some trusts don't even have SATs as part of them) and it can never in any way shape or form be a replacement for good practice or Nursing intuition. However, I HAVE found it to be a useful tool when writing up or when my intuition and knowledge says that a patient is worsening, it provides a protocol that says a Doctor must come and assess the patient at a certain stage, it is this protocol that I have on occasion found use for and have used to force action out of otherwise indifferent medical staff. It is also a good indicator of vital trends in the patients condition, alongside other tools of course. It isn't perfect, but as long as it is used in context (and filled in correctly and consistently by other staff!) with other tools, then it can be useful.

I agree entirely. So much is into schemes and systems and yet the true nurse (so I was told in my training in the 80s) looks at the patient as a whole from head to toe noticing vital signs, verbal and non verbal responses and then develops an instinct that is totally patient contact led and tells you straight away something is up. This instinctive reaction is often faster than filling in another form as mentioned in article above. Certain things trigger warnings and certain knowledge and logic makes sense of them. Are we now too cleve for basics. Is that what degree nursing does (oh and by the way I do have a degree but learned common sense first).

In many ways I agree with the author, and her comments are thought provoking. However in this day and age where we are required to justify every action and reaction then the EWS/METS or MEWS aids this. In addition when phoning a Dr to attend to a patient it provides a more structured and robust format and can aid decision making. Unfortunately the old times are gone, and even the good clinical nurse with expertise in patient assessment who knows when there is a problem sometimes needs a tool like this to motivate others to act.

We use the EWS at work, and I hate it. Sometimes (on nights especially), if I'm trying to get a doctor to come see a patient with deteriorating obs, all they are interested in is what the EWS is, and why, if the score is 0 or 1 (eg, a post op patient with a falling bp and rising pulse, but which is not yet triggering a score), why I am asking them to review the patient.

The EWS is to assist HCA (Non trained)to report observsation recording which do not fall within the normal range. The Nurse need to be informed promptly. In doing so the Nurse can take the appropriate actions. However this is providing the HCA is sensible to report the findings.

Unfortunately I have had experienced where some HCA do not report observations which are out of range. As a result I personally record the vital signs of each patient I nurse whilst on duty and by doing this I am able to act upon those obs which are out of range.

I have been doing some reading on American Nursing Theory and as a trained UK Nurse I must say I have learnt alot and I certainly take it as a positive and try to apply it to my care delivery.

I totally agree - i don't use early warning scores because i don't need to, i know what normal parameters are and i can interpret patients vital signs and think critically about their condition, past medical history etc (as other posters have written about COPD patients etc).However i do see their usefulness when untrained staff are taking vital signs as long as those staff are trained to use the scores properly.

How correct you are, but we are so dependant upon non registered staff undertaking these skills and all too often they have absolutely no idea about the 1. significance of what they are undertaking,2. how to undetake this properly, ie what you learn from holding the wrist to assess the pulse, not just the rate - similarly with the respirations3. The unreliability of relying on equipment,

Some non reg have been brilliantly trained, others by just 'ticking the box.'

As the RN is accountable, and patients lives are at stake, we train all of our own - and assess them individually both how to undertake this and how to use score tool, and reasses annually.

I recently underwent major surgery. Knowing what is normal for my vital signs I was astounded to be told by a qualified nurse that I was well just because my vitals were within the normal range... hence feeling really poorly - bounding pulse, nausea, headache, wound site pain and extremely dizzy I was just about dragged from my bed to the treatment room by two auxillaries, under the instruction of the qualified nurse, and had a drain removed... without the qualified nurse present... I wonder if this is normal practice in post surgical care... being mental health trained my only experience of general nursing is when I am a patient... god forbid i have to suffer such an experience again...

As a nurse trained in the 80's in the UK and further training in the US in 2000 I can see both sides.

I have been back in the UK for 5 years working in acute areas.

My experience in the US showed that the basic ADL's were provided by the nurses aids. Meds were dispensed by a computerised system and IV antibiotics came allready mixed. ECG's and Nebulisation was not done by the nurses on the ward. Cardiac patients had telemetry and CCU had a nurse sitting in front of all the monitors and would call the ward with any abnormalities.. There were many other proceedures not provided by the nurses on the ward itself.

In the UK the ward nurses give all care and perform proceedures, Ecg's, nebulization, suction and cardiac patients are on monitors by the bed which the ward staff have to interpret also. Nurses calculate and mix IV's for administration and medication is in a large general trolley for the whole ward.

Duties for UK nurses are overwhelming at times. HCA's record observations, but many do not know how to interpret the results. EWS and other scoring systems have therefore become a tool to aid in deteriorating patients being highlighted. Without this tool currently in place, many patients could be left to deteriorate until the trained nurse has time to check the obs. With HCA's knowing to report a higher score immediately, patients are reviewed quicker.

Is this ideal??? NO.. It would be wonderfull if trained nurses had the time to provide appropriate care, while new staff nurses and other team members were mentored and experience passed on to them. There are not enough nurses.....

At present with wards dangerously short staffed, high nurse-patient ratio's and higher admission rates, to remove the EWS and other scoring systems will lead to more patients left in beds deteriorating, only being discovered when the trained nurse has time to check the charts or someone passing sees a patient looking like they are about to crash.

I read many articles about the best way to deliver care and most of them are great in principal... The only problem is putting them into practise.

I dream for the days when there are enough experienced nurses to provide excellent patient care and able to mentor newer staff... I dream... Back to work now, probably to find another risk assessment chart thats oh, so much better than the last one.....

I personally think that the use of the EWS is vital towards documentation, a way of recording.

As a sudent nurse in my final year I clearly state at my uni we are taught to look at the patient as a whole,not just the EWS, and I certainly know if I have a problem from the obs alone and do not require the EWS to tell me.

On the contrast having lived in the US, and attending emergancy department with a child, no treatment is given without first showing insurance card or cash. I wonder why the EWS is that bad? perhaps both side of the pond need to rethink?

My trust not only makes the nurses do EWS on EVERY patient EVERY 12 hours, they also make us audit them every week to make sure they are getting done!We also face a telling off if the EWS are not done the minute before a patient is discharged home. So picture the scenario,A patient declared fit for home, bags packed, taxi booked, looking forward to getting out of this horrible place, then, "Oh no, whats wrong, you said I was okay, why are you taking my blood pressure again?, what? its high?, youll have to speak to the doctor before I go?"

Good debate. Just wanted to say to anon. 7/3/10 9.53am, I expect they wondered why you had not sat with each and every one of those patients and fed them their meals as well! Sorry to digress, I just could not resist it........ ahh the good old NHS........

In defence of EWS, it is prudent to realise why they came into being. Comprehensive Critical Care, NCEPOD - An Acute Problem, NICE Clinical Guideline 50, NPSA reports, the list goes on. These all detail incidents of patients whose deterioration has not been recognised or acted upon. As professionals we should embrace any tool that aids us in ensuring patient safety. Time consuming? I don't think so, if you have a very basic grasp of maths and can count it isn't a problem - I am more concerned that observations are performed using non-invasive blood pressure devices. If a pulse rate and respiratory rate are properly recorded i.e. manually then the time spent calculating an EWS score is minimal.With the advent of EWS I have seen observations at last being completed, yes at last, the respiratory rate is recorded!!But the EWS is not a panacea it is not designed to replace the science and skill of nursing but to complement it. It isn't rocket science to understand that one tool cannot cover all eventualities - the prime example being pre-eclampsia where a systolic blood pressure of 160mmHg warrants intervention, or the situation as previously stated of COPD patients - but in these situations there is other guidance. For example the British Thoracic Society guidance for COPD patients. For those that think that they don't need to record EWS then they should think about the trends that are being observed. The downside to EWS is the unproven specificity - but they are developed by expert knowledge and until something better comes along we should embrace the concept in the knowledge that this tool can assist us in ensuring patient safety.

I think its ok because in this era of litigation,espescially America where they "no nothing" of that. It provides documented proof for nurses to both protect themselves and also make it hard for them to deny if they do not act promptly. Please remember that aside from obs and mews..we do have a hundred other things to do. We do need help sometimes.

I'm no against MEWS in themselves, but I do agree that nurses should be able to spot problems without them. in my trust they're only used for patients who are likely to have problems. More worryingly, the trust has just introduced colour-coded obs charts so whoever is doing the obs can identify whether or not they are normal.

I had a problem where a doctor on listening to the observations did not come and see the patient but on ringing back and informing him the pt was MEWSing at 6 now instead of 7 decided that he would, the deskilling of all team members is happening

I just dropped in to say what a wonderful series of articles this UK v US stuff by Sara Morgan is turning out to be... I am hoping it becomes a 'regular' column instead of just a 'special!'

Why? Well, I am living the reverse side of the coin! Yup, I am a UK-trained Registered Nurse (RMN SRN) who has been practising in Canada for the last ten years (oh yeah I did a few other countries inbetween times too - but that's another story!)

It tickles my funny-bone to read Sara's experiences because they mirror so many of my own terminally-bewildered ones.

Comparative "Nursing" (as a concept) around the world is always going to be an "inexhaustible well" of totally interesting and absorbing articles by any "globally-challenged" nurse who can string a coherent observation about different cultural nursing "norms" into a well written and cogent article. Sara is doing just that. She's a gem and the NT needs to keep publishing her musings for as long as she can keep writing them.

Just for your information - and for the sanity of my former UK colleagues - there is as much nonsense on "this side" of the pond as Sara reports upon in my former abode.

For example... in Ontario (akin to ER and A&E)... for EWS, just read in the initials MDS... a similar stupidity designed ONLY to combat the rabid North American infectious disease commonly known as "litigation" or "money-for-nothing" as propagated by the law-firm of "Sue, Grabbitt and Runn."

Keep writing it up Sara and I will keep reading it. Even more interesting and (professionally) thought provoking than "Beyond The Bedpan!"

The EWS method is good. Not all nurses are experienced (think newly qualified). As previoulsy stated nurses in the UK are rushed off their feet so anything that can help is appreciated and the EWS helps.

I'm really not sure what sara morgan is getting at.

Again my experience of US health care is also one based on financial gain. Why is Obama so keen to see this altered? Because 40 million us citizens are without health insurance. The US may be good at lots of things...it is abysmal at looking after the health of it's citizens.

I am glad this has been raised and wish if HCAs have to take obs they should be able to assess for any deterioration in patients rather than waiting for the additon of the EWS. As a nurse i support the idea of of being able to assess and intervene ASAP.

I came to nursing late and at 45 am still in my third year of training. It took me about five minutes on my first ever ward placement about 8 weeks into my training to work out that HCA's were filling in mews sheets with absolutely no idea what the numbers meant. They walked down the ward plugging patients into the machines and recording the results with no ability whatsoever to interpret the result or understand it. No attempt was made to calibrate the monitoring equipment and as far as I could tell no trained member of staff made any attempt to inspect charts or check for any kind of pattern or trend. On a surgical ward this alarmed me and I made a point of ensuring I always checked the observation charts at least twice each shift.

Although I have never practiced in the UK, the art of caring for the patient shouldn't differ that greatly. The bedside nurse should be quite adept at interpreting changes in patients vital signs without the aid of some stupid calculation. Nurses are educated to trend patients vitals and to notice subtle changes prior to them becoming a problem. If you wish to wait and have some EWS to make a determination if a patient has deteriorated it is too late. Also if you want to score things why hire educated nurses to care for our patients ?As far as the comments about the US healthcare system let me make three points.1. ER's are required to evaluate all patients before they can even ask who/how the bill will be paid.2. The obama attempt to take over the healthcare system is more of a political move to mimic that systems of europe. Hmmm 25 patients to 1 nurse and a teenager is not something we need or want. Truly is his big power grab to move our country to be socialized like your own. 3. The healthcare and the healthcare providers in the US are the most innovative in the world.

We love our partners in the UK but please don't listen to all the news about our country.

As part of my training we are taught that SEWS charts are a great way of covering our backs. As one of my lecturers is fond of saying "if it is not charted it has not been done"I like them because you can see a trend forming for all of your observations on one chart.I am not saying that they should take cognition out of nursing though. You should be able to tell when your patient is unwell without the chart infront of you.

Agreed! EWS is just to cover up the fact that nursing schools actually don't teach any in depth science whatsoever. Why because they don't know either.

The quality of new nurses graduating is pretty lousy especially on clinical knowledge. i started to study harder from the first year because it became obvious that the nursing programme was going to leave me and hundreds of others stranded at the end with a highly inferior level of general knowledge and skills.

Until our educational elite (sic) admit that they teach about 1/5 of the required nursing curriculum and should step it up we will always be behind.

Don't forget that these lecturers have very little confidence and faith in nursing students and treat them as school children rather than adults.

and p.s. to whoever wrote the US healthcare is innnovative.It's not innovative if ordinary people can't afford it and your insurance industry actively tries to remove patients from the list.

it's not innovative when cheap drugs cost 100% more than it costst to buy or make them and it's not innovative if you can't offer it to a wide number of people.

What you mean is 'some people in the USa receive innovative healthcare so long as they can pay for it, most on the other hand are at the mercy of family doctors and small hospitals with basic services.

Don't forget Americans, we know far far more about your country than you do about ours, or even the continent our country is situated in.

Try to differentiate between the countries if you please. None of them have the same type of healthcare model and none of them are 'socialized', that's a term invented by scaremongering republicans.

Besides if anyones healthcare system is socialized it's yours seeing as it is engineering to work for one part of society - the rich!

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